Vision Statement template
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The document is a Nebraska Department of Motor Vehicles (DMV) Statement of Vision form for reporting an applicant's visual condition and history to the DMV. The form consists of two pages, with page 1 requiring information such as the applicant's name, address, date of birth, license number, and various vision test results. Test results include unaided and corrected acuity for both eyes, extent of horizontal form field, diplopia status, color blindness capacity, and the need for retesting in specific years. Page 2 includes questions regarding significant worsening or development of vision conditions prior to July 30, 1996, and questions specifically for commercial motor vehicle operators. The optometrist or ophthalmologist completes sections requiring professional expertise.
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